Chronic treatment regimen using glucagon-like insulinotropic peptides

ABSTRACT

The present invention encompasses a method of treating a disease by maintaining chronic steady state serum levels of a GLP-1 compound within a specified range.

This is the national phase application, under 35 USC 371, forPCT/US01/44698, filed Dec. 7, 2001, which claims the priority of U.S.provisional application Nos. 60/298,652, filed Jun. 15, 2001, 60/295,655filed Jun. 4, 2001, and 60/255,251 filed Dec. 13, 2000.

1. Field of the Invention

The present invention relates to a chronic treatment regimen usingglucagon-like insulinotropic peptides in pharmaceutical articles ofmanufacture and methods.

2. Background Information

The intestinal hormone glucagon-like peptide-1 (GLP-1) shows greatpromise as a treatment for type 2 diabetes due to its ability tostimulate insulin secretion, lower glucagon secretion, inhibit gastricemptying, enhance glucose utilization, and induce appetite suppressionand weight loss. Further, pre-clinical studies suggest that GLP-1 mayalso act to prevent the β-cell deterioration that occurs as the diseaseprogresses. Perhaps the most salient characteristic of GLP-1 is itsability to stimulate insulin secretion without the associated risk ofhypoglycemia that is often seen when using insulin therapy and sometypes of oral therapies. When blood glucose levels drop to a certainthreshold level, GLP-1 is not active.

However, the usefulness of therapy involving GLP-1 peptides has beenlimited by the fact that GLP-1(1-37) is poorly active, and the twonaturally occurring truncated peptides, GLP-1(7-37)OH andGLP-1(7-36)NH₂, have extremely short half-lives and are rapidly clearedfrom the circulation. Thus, research related to GLP-1 has focused on thedevelopment of GLP-1 analogs, GLP-1 derivatives, and formulationsthereof which provide a more extended time action. Despite much progressin this area of development, there are no published papers reporting onclinical data in humans using long-acting GLP-1 analogs or derivatives.Until the present invention, it has been unclear whether steady statelevels of a GLP-1 compound with a particular potency can be safelymaintained for a lengthy course of treatment and continue to provide thebenefits associated with the activities that have been elucidated forendogenous GLP-1.

Some short-term clinical studies with native GLP-1 which requirecontinuous infusion or frequent dosing suggest that high concentrationsof GLP-1 cause frequent nausea and vomiting. This has raised concernamong clinicians that these undesired effects will limit the dosage andthus, limit the efficacy even though the drug inherently may be capableof producing a greater effect.

There are several published clinical studies involving administration ofnative GLP-1(7-37)OH to patients by i.v. or subcutaneous continuousinfusion. See Naslund, et al. (1999) Am. J. Phys. 277(3):1-14; Deacon,et al. (1995) Diabetes 44:1126-1131; Toft-Nielsen, et al. (1999)Diabetes Care 22(7):1137-1143. The published studies consistently use adose between about 0.75 pmol/kg/min and 2.4 pmol/kg/min for shortperiods of time. However, because GLP-1(7-37)OH is rapidly degraded uponexposure to plasma, it is not always clear what levels of intact/activeGLP-1 peptide are present in the plasma at a given time point.

Naslund, et al., nevertheless, were able to predict plasma levels ofintact GLP-1(7-37)OH after continuous administration at a rate of 0.75pmol/kg/min for 180 min. The authors used a sandwich radioimmunoassy todetect both N-terminally degraded and intact GLP-1(7-37)OH. Plasmalevels of intact GLP-1 were approximately 20 picomolar for the last 120min. of treatment. Using a similar assay, Toft-Nielsen et al. reportedintact GLP-1 levels of approximately 10.2 picomolar and 22.5 picomolarafter administration of 1.2 pmol/kg/min and 2.4 pmol/kg/min,respectively.

These studies, however, have not answered the question whether plasmalevels of intact and active GLP-1 can be achieved to achieve therapeuticbenefit while at the same time avoiding or minimizing side effects suchas nausea and vomiting. Similarly, these studies do not indicate whetherplasma levels of active GLP-1 should be relatively flat during treatmentor whether peaks and valleys, which would mimic the physiological state,would be preferred. Thus, despite considerable progress, there remains aneed to discover and understand what treatment regimen leads toeffective long-term therapy and whether such treatment can be maintainedwith minimal side effects such as nausea and vomiting.

Applicants have discovered that maintaining continuous plasma levels ofa GLP-1 compound in a specific range provides effective treatment. It isbelieved that the absence of peaks and valleys avoids or minimizes sideeffects such as nausea and vomiting. Accordingly, the present inventionprovides a chronic treatment regimen which comprises maintainingcontinuous plasma levels of a GLP-1 compound within a certain range thatavoids or minimizes side effects such as nausea and vomiting. The plasmalevels encompassed by the present invention provide optimal bloodglucose control. Furthermore, this treatment regimen provides long-termpositive health effects including the inducement of weight loss,improvement of β cell function, activation of dormant β cells,differentiation of cells into β cells, β cell proliferation, and themaintenance of organ function.

The present invention encompasses a method of normalizing blood glucoselevels, preventing β cell deterioration, inducing weight loss, ortreating a condition selected from the group consisting of:hyperglycemia, type 2 diabetes, obesity, stroke, myocardial infarction,catabolic changes that occur after surgery, and irritable bowelsyndrome, which comprises maintaining chronic steady state plasma levelsbetween about 60 picomoles/liter and about 200 picomoles/liter of aGLP-1 analog or derivative in a biologically active form having an invitro potency within two-fold the in vitro potency of Val⁸-GLP-1(7-37)OHwherein the GLP-1 analog or derivative is administered by subcutaneousinjection no more than once or twice every 24 hours.

The present invention also encompasses a method of normalizing bloodglucose levels, preventing β cell deterioration, inducing weight loss,or treating a condition selected from the group consisting of:hyperglycemia, type 2 diabetes, obesity, stroke, myocardial infarction,catabolic changes that occur after surgery, and irritable bowelsyndrome, which comprises maintaining chronic steady state plasma levelsbetween about 60/X picomolar and about 200/X picomolar of a GLP-1 analogor derivative in a biologically active form wherein X is the in vitropotency of the GLP-1 analog or derivative relative to Val⁸-GLP-1(7-37)OHwhich is a given a value of 1 and wherein the GLP-1 analog or derivativeis administered by subcutaneous injection no more than once or twiceevery 24 hours.

The present invention also encompasses use of a GLP-1 analog orderivative having an in vitro potency within 2-fold that ofVal⁸-GLP-1(7-37)OH for the manufacture of a medicament for normalizingblood glucose, preserving β cells, inducing weight loss, or treating acondition selected from the group consisting of: hyperglycemia, type 2diabetes, stroke, myocardial infarction, catabolic changes that occurafter surgery, obesity, and irritable bowel syndrome which comprisesmaintaining chronic steady state plasma levels of the GLP-1 analog orderivative between about 60 picomolar and about 200 picomolar andwherein the GLP-1 analog or derivative is administered by subcutaneousinjection not more the once or twice every 24 hours.

The present invention also encompasses use of a GLP-1 analog orderivative for the manufacture of a medicament for normalizing bloodglucose, preserving β cells, inducing weight loss, or treating acondition selected from the group consisting of: hyperglycemia, type 2diabetes, stroke, myocardial infarction, catabolic changes that occurafter surgery, obesity, and irritable bowel syndrome which comprisesmaintaining chronic steady state plasma levels of the GLP-1 analog orderivative between about 60/X picomolar and about 200/X picomolarwherein X is the in vitro potency of the GLP-1 analog or derivativerelative to Val⁸-GLP-1(7-37)OH which is given a reference value of 1 andwherein the GLP-1 analog or derivative is administered by subcutaneousinjection no more than once or twice every 24 hours.

The invention also encompasses an article of manufacture for humanpharmaceutical use comprising a container; a dosage form comprising anamount of a GLP-1 analog or derivative having an in vitro potency withintwo-fold that of Val⁸-GLP-1(7-37)OH, and a package insert that providesfor administration of the dosage form that results in maintaining GLP-1analog or derivative plasma levels between about 60 picomolar and about200 picomolar.

FIG. 1: Graphs representing the mean (+/−SEM) plasma Val⁸-GLP-1(7-37)OHconcentrations following once-daily administration of placebo(baseline), 2.5 mg (Group 1), and 3.5 mg (Group 2) of Val⁸-GLP-1(7-37)OHto patients with type 2 diabetes.

FIG. 2: Graphs representing the mean (+/−SEM) glucose concentrationsfollowing once-daily administration of placebo (baseline), 2.5 mg (Group1), and 3.5 mg (Group 2) of Val⁸-GLP-1(7-37)OH to patients with type 2diabetes.

FIG. 3: Graphs representing the mean (+/−SEM) plasma Val⁸-GLP-1(7-37)OHconcentrations following once-daily administration of placebo (baseline)and 4.5 mg (Groups 3 and 4) of Val⁸-GLP-1(7-37)OH to patients with type2 diabetes.

FIG. 4: Graphs representing the mean (+/−SEM) glucose concentrationsfollowing once-daily administration of placebo (baseline) and 4.5 mg(Groups 3 and 4) of Val⁸-GLP-1(7-37)OH to patients with type 2 diabetes.

For purposes of the present invention as disclosed and described herein,the following terms and abbreviations are defined as follows.

A “treatment regimen” is the administration of a GLP-1 compound suchthat optimum plasma levels are chronically maintained. The GLP-1compounds used for the regimen of the present invention exert theirbiological effects by acting at a receptor referred to as the GLP-1receptor. Subjects with diseases and/or conditions that respondfavorably to GLP-1 receptor stimulation or to the administration ofGLP-1 compounds can therefore be treated with the regimen of the presentinvention.

Thus, this regimen provides a variety of positive effects including butnot limited to treating hyperglycemia, maintaining blood glucosecontrol, treating type 2 diabetes, treating obesity, inducing weightloss, treating stroke, treating myocardial infarction, treatingcatabolic changes that occur after surgery or for other reasons,treating irritable bowel syndrome, preventing β-cell deterioration,inducing β-cell proliferation, stimulating insulin gene transcription,up-regulating IDX-1/PDX-1 or other growth factors, improving β-cellfunction, activating dormant β-cells, differentiating cells intoβ-cells, and/or β cell replication. Positive effects that result frommaintaining blood plasma levels within a specific range over extendedtime periods include an amelioration of the symptom(s) associated withthe disease or condition being treated, a delay in the onset of symptomsassociated with the disease or condition being treated, increasedlongevity compared with the absence of the treatment, and/or a greaterquality of life compared with the absence of the treatment. Furtherbenefits provided by the treatment regimen of the present inventionwhich relate to the treatment of type 2 diabetes and associatedhyperglycemia include enhanced convenience due to the elimination orreduction of blood glucose self-monitoring and administration of drugthat need not be timed with meals.

“Chronic therapy” refers to maintaining blood plasma levels of activeGLP-1 compounds within a specific range for a course of therapy. Thespecified range corresponds to plasma levels of active GLP-1 compoundsthat provide optimal efficacy and yet do not cause or at least minimizeside effects such as nausea and vomiting. A planned course of therapywill differ depending on the condition or disease being treated. Forexample, a planned course of therapy for a type 2 diabetic wherein oralmedications are no longer able to control blood glucose levels wouldencompass that time period wherein the patient has adequate β cellfunction to respond to GLP-1 receptor stimulation. A planned course oftherapy for an obese patient or a patient desiring to lose weight wouldencompass that time period until the patient has reached a normal weightbased on the patient's height and build. A planned course of therapy mayalso have a prophylactic goal such as to prevent the progression of type2 diabetes, the development of diabetes, impaired glucose tolerance,syndrome x, or to prevent weight gain. This type of therapy couldpotentially last a patient's lifetime.

“Chronic” generally refers to regular administration for an extendedperiod preferably not more frequently than twice daily, most preferablynot more than once daily. However, chronic administration as used hereinmay encompass other regimens in addition to once or twice daily dosing.For example, chronic administration encompasses administration of asustained release formulation that provides sufficient therapeutic bloodplasma levels on a regular basis. Such administration may includeadministration once a week, once a month, or even less frequently.Contrary to acute or on-demand administration, chronic administrationdoes not link administration of drug to events such as meals, results ofhome glucose monitoring, or need for appetite suppression.

“Insulinotropic activity” refers to the ability to stimulate insulinsecretion in response to elevated glucose levels, thereby causingglucose uptake by cells and decreased plasma glucose levels.Insulinotropic activity can be assessed by methods known in the art,including using in vivo experiments and in vitro assays that measureGLP-1 receptor binding activity or receptor activation, e.g., assaysemploying pancreatic islet cells or insulinoma cells, as described in EP619,322 to Gelfand, et al., and U.S. Pat. No. 5,120,712, respectively.The entire teachings of these references are incorporated herein byreference. Insulinotropic activity is routinely measured in humans bymeasuring insulin levels or C-peptide levels.

“Container” means any receptacle and closure suitable for storing,shipping, dispensing, and/or handling a pharmaceutical product.

“Packaging” means a customer-friendly device allowing convenientadministration and/or ancillary devices that aid in delivery, education,and/or administration. The packaging may improve GLP-1 compoundadministration to the patient, reduce or improve educational instructiontime for the patient, provide a platform for improved health economicstudies, and/or limit distribution channel workload. Also, the packagingmay include but not be limited to a paper-based package, shrink wrappedpackage, see-through top packaging, trial-use coupons, educationalmaterials, ancillary supplies, and/or delivery device.

“Package insert” means information accompanying the product thatprovides a description of how to administer the product, along with thesafety and efficacy data required to allow the physician, pharmacist,and patient to make an informed decision regarding use of the product,and/or patient education information. The package insert generally isregarded as the “label” for a pharmaceutical product.

A “subject” or “patient” is a human.

“In vitro potency” as used herein is the measure of the potency orability of a compound to activate the GLP-1 receptor in a cell-basedassay. In vitro potency is expressed as the “EC₅₀” which is theeffective concentration of compound that results in 50% activity in asingle dose-response experiment. For the purposes of the presentinvention, in vitro potency is determined using a fluorescence assaythat employs HEK-293 Aurora CRE-BLAM cells that stably express the humanGLP-1 receptor. The assay is discussed in more detail on page 17 and inexample 3. The in vitro potency values as disclosed herein are expressedas the EC₅₀ which was established by generating a dose response curveusing dilutions resulting in GLP-1 compound concentrations from 3nanomolar to 30 nanomolar. Relative in vitro potency values areestablished by running Val⁸-GLP-1(7-37)OH as a control and assigning thecontrol a reference value of 1.

The GLP-1 compounds of the present invention have sufficient homology toGLP-1(7-37)OH or a fragment of GLP-1(7-37)OH such that the compound hasthe ability to bind to the GLP-1 receptor and initiate a signaltransduction pathway resulting in insulinotropic action or otherphysiological effects as described herein such as inhibition of glucagonand delay in gastric emptying. For example, GLP-1 compounds can betested for insulinotropic activity using a cell-based assay such as thatdescribed in EP 619 322 which is a modification of the method describedby Lacy, et al. (1967) Diabetes 16:35-39. A collagenase digest ofpancreatic tissue is separated on a Ficoll gradient (27%, 23%, 20.5%,and 11% in Hank's balanced salt solution, pH 7.4). The islets arecollected from the 20.5%/11% interface, washed and handpicked free ofexocrine and other tissue under a stereomicroscope. The islets areincubated overnight in RPMI 1640 medium supplemented with 10% fetalbovine plasma and containing 11 mM glucose at 37° C. and 95% air/5% CO₂.The GLP-1 compound to be studied is prepared at a range ofconcentrations, preferably 3 nanomolar to 30 nanomolar in RPMI mediumcontaining 10% fetal bovine plasma and 16.7 mM glucose. About 8 to 10isolated islets are then transferred by pipette to a total volume of 250μl of the GLP-1 compound containing medium in 96 well microtiter dishes.The islets are incubated in the presence of the GLP-1 compound at 37°C., 95% air, 5% CO₂ for 90 minutes. Then aliquots of islet-free mediumare collected and 100 μl thereof are assayed for the amount of insulinpresent by radioimmunoassay using an Equate Insulin RIA Kit (Binax,Inc., Portland, Me.).

It is preferred that the GLP-1 compounds of the present invention havean in vitro potency no more than 10-fold lower than the in vitro potencyof Val⁸-GLP-1(7-37)OH. Preferably, the GLP-1 compounds have an in vitropotency not lower than the in vitro potency of Val⁸-GLP-1(7-37)OH.Representative GLP-1 compounds are discussed in detail below.Furthermore, the GLP-1 compounds used in the chronic treatment regimendescribed herein may require modification or formulation such that bloodplasma levels are maintained in the claimed efficacious range forextended time periods. Modification and formulation of GLP-1 compoundsis also discussed in detail below.

Although GLP-1 has been proposed as a possible therapy for type 2diabetes, its short half-life and susceptibility to protease degradationhas made it a difficult molecule to study. Furthermore, side effectssuch as nausea and vomiting have been observed after a singlesubcutaneous or i.v. bolus administration of active GLP-1. Applicantsbelieve this is due to the initial peak levels of the compound that areobtained immediately after administration. In order for a short actingformulation to provide a therapeutic benefit, it must be injected at ahigh enough dose to provide blood levels that are in the therapeuticrange at least long enough to achieve a glucose lowering effect after ameal. These undesired effects occurring after administration of arelatively high dose of a short-acting GLP-1 formulation limit theamount that can be administered to patients and correspondingly limitsthe efficacy.

Clinical studies have established several of the physiological effectsof GLP-1 which include stimulation of insulin secretion, inhibition ofglucagon secretion, decrease in hepatic glucose production, inhibitionof gastric emptying, and promotion of weight loss. However, GLP-1compounds cannot be effectively used in a treatment regimen unlesspharmacological levels of active GLP-1 are present continuouslythroughout the course of treatment. This is particularly true in orderto fully exploit blood glucose lowering potential as well as otherlong-term physiological effects described herein.

Accordingly, the present invention describes the steady state plasmalevels of an active GLP-1 compound having a specific potency necessaryto achieve efficacy yet avoid or minimize side effects such as nauseaand vomiting. The steady state concentration of a drug is achieved whendrug elimination which is a product of clearance and concentrationequals the rate of drug availability. In the context of intermittentdosage, during each interdose interval, the concentration of drug risesand falls. At steady state, the entire cycle is repeated identically ineach interval. However, as discussed herein, marked fluctuations inactive GLP-1 plasma concentrations between doses is responsible for sideeffects such as nausea and vomiting and do not result in an optimalbiological response.

The treatment regimen of the present invention involves administering aGLP-1 compound such that continuous steady state plasma levels of thecompound are maintained throughout a particular course of treatment fora particular condition. In the context of the present invention,“maintaining” plasma levels means that the plasma concentration of drugduring the course of treatment does not fluctuate significantly oncesteady state levels are achieved and thus, side effects such as nauseaand vomiting are avoided or minimized and at the same time an optimaltherapeutic effect is obtained. Drug levels do not fluctuatesignificantly if they remain within the claimed efficacious range oncesteady state plasma levels are achieved. Surprisingly, it was discoveredthat the therapeutic plasma levels for exogenously administered GLP-1compounds having a similar potency to native GLP-1 is significantlyhigher than levels of endogenously secreted GLP-1 in the circulation.

The present invention is based on data generated from a clinical trialwherein a long-acting GLP-1 formulation was administered viasubcutaneous injection once a day at three different dose levels. Aftersix days of dosing, drug levels reached a steady state plateau that wasmaintained continuously during the course of treatment. The chronictreatment regimen of the present invention may involve a GLP-1 compoundadministered continuously in order to obtain plasma levels within therange described herein or more preferably involves the administration ofa long-acting GLP-1 compound. Long acting in the context of the presentinvention means that the plasma levels of an active GLP-1 compound staywithin the therapeutic range described herein for at least 12 hoursafter delivery of a single dose. Preferably plasma levels remain withinthis range for at least 24 hours after delivery of a single dose. Thispreferred time action would result in once a day dosing.

Following administration of a sustained release formulation containingVal⁸-GLP-1(7-37)OH on day 1, mean Cmax values of 105, 147, 300, and 222pg/mL were achieved for doses corresponding to 2.5 mg, 3.5 mg, and twogroups at 4.5 mg, respectively. These Cmax values represent the meanmaximum plasma concentration of intact Val⁸-GLP-1(7-37)OH achieved for agroup of 8 patients at one of the given doses during the first day oftreatment. (See FIGS. 1 and 3). The plasma concentration ofVal⁸-GLP-1(7-37)OH for all three groups resulted in some glucoselowering with levels above 200 pg/mL showing the most significant effect(Table 1). Inspection of the mean plasma profiles suggested that steadystate was essentially attained after once a day dosing for 6 days andthat the accumulation of drug was approximately 3-fold. On day 6, themean Cmax values for the 2.5 mg, 3.5 mg, and 4.5 mg dosage groups were534, 525, and 570 pg/mL, respectively. The corresponding AUC₍₀₋₂₄₎values which represent exposure to the active drug were also similar:8878, 9846, and 10619 ng*h/L, respectively. Thus, a 1.8-fold increase indose was associated with a 1.2-fold increase in the mean steady stateexposure AUC(0-24) (See FIGS. 1 and 3).

TABLE 1 Dose (mg)/ Day 0 Group Parameter (Placebo) Day 1 Day 6 Day 212.5/1 R_(max) 267 (17.0) 246 (19.3) 205 (16.3) — (mg/dL) AUC₍₀₋₄₎ 901(18.8) 833 (19.2) 654 (21.2) — (mg * h/dL) 3.5/2 R_(max) 265 (15.9) 214(23.9) 175 (14.7) — (mg/dL) AUC₍₀₋₄₎ 871 (18.2) 738 (22.2) 557 (14.3) —(mg * h/dL) 4.5/3 R_(max) 287 (22.5) 244 (29.3) 221 (34.9) — (mg/dL)AUC₍₀₋₄₎ 995 (24.1) 834 (31.5) 704 (35.0) — (mg * h/dL) 4.5/4 R_(max)226 (15.1) 177 (22.0) 159 (20.2) 156 (26.6) (mg/dL) AUC₍₀₋₄₎ 759 (14.8)592 (20.4) 529 (21.0) 516 (33.5) (mg * h/dL) Abbreviations: R_(max) =mean maximum concentration; AUC = area under the curve.

A clinically relevant fall in the pre-dose fasting blood glucose wasseen after dosing in all treatment groups. The mean maximum observedglucose concentrations represented as Rmax ranged from 23% to 34% lowerthan the placebo controlled group on the sixth day of treatment.Furthermore, the glucose response of day 6 was similar to that seenafter 21 days of treatment (See FIGS. 2 and 4). A plateau in theresponse was achieved at steady state concentration corresponding to the2.5 mg and 3.5 mg doses which resulted in mean Cmax values of 534 and525 pg/mL, respectively. Unexpectantly, no severe nausea and vomitingand only occasional, generally short episodes of nausea or vomiting wasobserved in groups having plasma levels below 600 pg/mL. One patientreceived a dose that resulted in a Cmax of 990 pg/mL ofVal⁸-GLP-1(7-37)OH and this higher level was associated with somenausea.

In addition, weight loss occurred in the treatment groups. The averageamount of weight loss per patient during the 21-day dosing period wasapproximately 2.1 kg.

Because there will be differences in the molecular weight of GLP-1compounds having similar potencies, the observed plasma levels forVal⁸-GLP-1(7-37)OH are converted from pg/mL to picomolar (pmoles/L).Thus, the preferred range of plasma levels that provide maximum efficacyand yet avoid or minimize side effects such as nausea and vomiting isbetween about 60 and about 200 pmoles/liter for GLP-1 compounds having apotency that is similar or within two-fold the potency ofVal⁸-GLP-1(7-37)OH. More preferably, plasma levels are between about 80picomolar and about 200 picomolar. Even more preferably, plasma levelsare between about 100 picomolar and about 200 picomolar.

Thus, the invention also relates to the use of a GLP-1 compound having apotency that is similar or within two-fold the potency ofVal⁸-GLP-1(7-37)OH for the manufacture of a medicament for thenormalization of blood glucose, preservation of β-cells, induction ofweight loss or the treatment of a condition selected from the groupconsisting of: hyperglycemia, type 2 diabetes, stroke, myocardialinfarction, catabolic changes that occur after surgery, obesity, andirritable bowel syndrome, wherein the medicament is adapted for chronicadministration such that chronic steady state plasma levels of the GLP-1compound are maintained between about 60 picomolar and about 200picomolar, preferably between about 80 picomolar and about 200picomolar, more preferably between about 100 picomolar and about 200picomolar

Plasma levels as discussed herein refer to the concentration of anactive GLP-1 compound as measured in blood plasma. Plasma contains anenzyme known as DPP-IV which readily cleaves amino acids at theN-terminus of GLP-1 compounds. It is known that GLP-1 must have anintact Histidine at the N-terminus to be active. For exampleGLP-1(7-37)OH is rapidly degraded to GLP-1(9-37)OH once it is releasedinto the plasma. GLP-1(9-37)OH is not active. Furthermore, GLP-1 canalso be inactivated by cleavage at the C-terminus. An inactiveGLP-1(7-33) metabolite has also been reported in the literature. Theplasma levels described herein for Val⁸-GLP-1(7-37)OH were measuredusing a sandwich radioimmunoassay. The assay makes use of an antibodythat specifically recognizes the intact amino-terminus ofVal⁸-GLP-1(7-37)OH in combination with another antibody which recognizesthe intact C-terminus of Val⁸-GLP-1(7-37)OH. Thus, only plasma levels ofactive Val⁸-GLP-1(7-37)OH are measured. (See Example 2).

Plasma levels of active GLP-1 compounds other than Val⁸-GLP-1(7-37)OHcan similarly be measured by generating antibodies by methods well-knownin the art that specifically identify the intact N-terminus of thecompound being tested and do not cross-react with native GLP-1.

Some GLP-1 derivatives such as Arg³⁴Lys²⁶-(N-ε-(γ-Glu(N-α-hexadecanoyl)))-GLP-1(7-37) are long-acting because they bind toplasma albumin and slowly dissociate from albumin and are released intothe plasma as unbound derivatives that can bind the GLP-1 receptor andinitiate a signal. For the purposes of the present invention, plasmalevels refer to the concentration of active GLP-1 derivatives such asArg³⁴Lys²⁶-(N-ε-(γ-Glu(N-α-hexadecanoyl)))-GLP-1(7-37) that are presentin the plasma not bound to albumin.

To achieve maximum efficacy while minimizing side effects, the plasmalevels of a GLP-1 compound should not fluctuate significantly oncesteady state levels are obtained during the course of treatment. Levelsdo not fluctuate significantly if they are maintained within the rangesdescribed herein once steady state levels are achieved throughout acourse of treatment. Most preferably, plasma levels of a GLP-1 compoundwith a potency similar to or within two-fold that of Val⁸-GLP-1(7-37)OHare maintained between about 100 picomolar and about 200 picomolarthroughout a course of treatment once steady state levels are obtained.For example, FIG. 3 depicts plasma levels of Val⁸-GLP-1(7-37)OH whichremain flat and do not fluctuate significantly over the course of 15days based on once a day dosing. Levels are maintained between about 400and about 600 pg/mL which corresponds to between about 120 picomolar and180 picomolar.

The optimal range of plasma levels appropriate for Val⁸-GLP-1(7-37)OHand GLP-1 compounds of similar potency (See Table 2) can also be appliedto other GLP-1 compounds including Exendin-3 and Exendin-4 which havedifferent potencies. GLP-1 compounds of similar potency includecompounds that have within two-fold the activity of Val⁸-GLP-1(7-37)OHas measured by an in vitro potency assay.

The preferred assay for the purposes of the present invention measuresEC₅₀ potency using HEK-293 Aurora CRE-BLAM cells that stably express thehuman GLP-1 receptor. These HEK-293 cells have stably integrated a DNAvector having a cAMP response element (CRE) driving expression of theβ-lactamase (BLAM) gene. The interaction of a GLP-1 agonist with thereceptor initiates a signal that results in activation of the cAMPresponse element and subsequent expression of β-lactamase. Theβ-lactamase CCF2/AM substrate that emits flourescence when it is cleavedby β-lactamase (Aurora Biosciences Corp.) can then be added to cellsthat have been exposed to a specific amount of GLP-1 agonist to providea measure of GLP-1 agonist potency. The assay is further described inZlokarnik, et al. (1998) Science 279:84-88 (See also Example 3). TheEC₅₀ values listed in Table 2 were determined using the BLAM assaydescribed above by generating a dose response curve using dilutions from3 nanomolar to 30 nanomolar.

Exendin-4 has a potency that is approximately 5-fold higher thanVal⁸-GLP-1(7-37)OH; thus, optimum plasma levels of Exendin-4 will beapproximately 5-fold lower than the levels appropriate forVal⁸-GLP-1(7-37)OH and compounds of similar potency. This wouldcorrespond to plasma levels in the range between about 6 picomolar andabout 40 picomolar, preferably between about 12 picomolar and about 30picomolar. Another example of a GLP-1 compound with increased potency isVal⁸-Glu²²-GLP-1(7-37)OH which has a potency approximately 3-fold higherthan Val⁸-GLP-1(7-37)OH. Thus, optimum plasma levels of this compoundwill be approximately 3-fold lower than the levels determined for.Val⁸-GLP-1 (7-37) OH.

TABLE 2 In vitro activity relative to GLP-1 Compound Val⁸-GLP-1(7-37)OHVal⁸-GLP-1(7-37)OH 1 Val⁸-GLP-1(7-36)NH₂ 1.06 GLP-1(7-37)OH 2.06GLP-1(7-36)NH₂ 1.50 Gly⁸-GLP-1(7-37)OH 1.67 Val⁸-Tyr¹²-GLP-1(7-37)OH1.73 Val⁸-Trp¹²-GLP-1(7-37)OH 1.07 Val⁸-Leu¹⁶-GLP-1(7-37)OH 1.13Val⁸-Lys²²-GLP-1(7-37)OH 1.22 Exendin-4 4.5 Val⁸-Glu²²-GLP-1(7-37)OH3.33 Val⁸-Arg²⁶-GLP-1(7-37)OH 1.47 Val⁸-Ala²⁷-GLP-1(7-37)OH 1Arg³⁴Lys²⁶-(N-ε-(γ-Glu(N-α- 1.92 hexadecanoyl)))-GLP-1(7-37)

Thus, the range of plasma levels appropriate for a GLP-1 compound with apotency that differs from that of Val⁸-GLP-1(7-37)OH can be determined.For example, a range of plasma levels for a particular GLP-1 compound isbetween about 60/X and 200/X, preferably between about 60/X and 150/X,most preferably between about 100/X and about 150/X wherein X is the invitro potency of the GLP-1 compound relative to Val⁸-GLP-1(7-37)OHwherein Val⁸-GLP-1(7-37)OH has a reference value of 1.

Further, the invention relates to the use of a GLP-1 compound for themanufacture of a medicament for the normalization of blood glucose,preservation of β-cells, induction of weight loss, or the treatment of acondition selected from the group consisting of: hyperglycemia, type 2diabetes, stroke, myocardial infarction, catabolic changes that occurafter surgery, obesity, and irritable bowel syndrome, wherein themedicament is adapted for chronic administration such that chronicplasma levels of the GLP-1 compound are maintained between about 60/Xpicomolar and about 200/X picomolar wherein X is the in vitro potency ofthe GLP-1 compound relative to Val⁸-GLP-1(7-37)OH which has a referencevalue of 1.

Maintaining plasma levels within the range discovered by the inventorsof the present invention provides numerous clinical benefits as well asbenefits from a patient convenience standpoint. There is little or norisk of hypoglycemia to the subject when using this treatment regimen.Additionally, this regimen minimizes invasive, planning, and/ortime-consuming events. Furthermore, the regimen provides convenience tothe patient by reducing blood glucose self-monitoring in conjunctionwith use. Most preferably, blood glucose self-monitoring is reducedsignificantly or eliminated for subjects using this treatment regimen.For example, this use does not require patient planning before, during,or following a meal. Most preferably, subjects do not need to link useof this regimen with any glucose, calorie, or sustenance consumptionevent of any quantity. Furthermore, use of this invention preferablylimits any dose titration needed for a subject to determine theeffective amount required. Most preferably, no dose titration isrequired thereby making one or two doses appropriate for all patients.

While pre-clinical data has alluded to some of the long-term healthbenefits associated with GLP-1 therapy, it has not been possible to takeadvantage of these long-term benefits in human patients due to the lackof understanding regarding the steady plasma levels required to achievesuch benefits.

Maintaining plasma levels of intact GLP-1 compounds as described hereininduce long-term benefits derived from the suppression of glucagon,upregulation of somatostatin, stimulation of insulin gene transcription,up-regulation of IDX-1/PDX-1 or other growth factors, improvement of βcell function, activation of dormant β cells, differentiation of cellsinto β cells, β cell replication, and β cell proliferation. For thepurposes of the present invention, a method of preserving β cells may bedue to all or some or one of the following effects: improvement of βcell function, activation of dormant β cells, differentiation of cellsinto β cells, β cell replication, preventing β-cell deterioration suchas by inhibition of apoptosis, and β cell proliferation.

Maintaining plasma levels of intact GLP-1 compounds as described hereininduce long-term benefits such as appetite suppression resulting inweight loss or lack of weight gain. For example, obesity and relatedconditions are treated or prevented by this chronic treatment regimen.Any and all reduction in weight via less weight gain, no weight gain,and/or weight loss provides the subject with overall positive physicaland psychological health effects, contributes to lessening risk factorslinked to excessive body weight, and enforces compliant use of thecompounds thereby reducing potential blood glucose excursions and itsconcomitant effects.

Another benefit of chronic exposure to GLP-1 compounds within the rangeof claimed serum levels includes the elimination of the delay on gastricemptying that occurs when GLP-1 compounds are first administered. Byanalyzing the timing of glucose peaks relative to the ingestion of ameal for patients receiving a GLP-1 compound, it was determined that thedelay in gastric emptying caused by the presence of a GLP-1 compound isapproximately 2 to 3 hours. Surprisingly, after 6 days of chronic GLP-1compound therapy, the analysis of glucose peaks indicated that thisdelay in gastric emptying was eliminated. Thus, chronic exposure toGLP-1 compounds within the claimed serum level range leads to anelimination of GI effects such as a delay in gastric emptying and,therefore, increases patient tolerability to the drug and potentiallyminimizes side effects.

This chronic treatment regimen may include treatment using GLP-1compounds along with other blood glucose lowering drugs such asmetformin, sulfonyl ureas, thiazolidinediones, and/or bisguanidines. Therange of plasma levels described herein is appropriate when GLP-1compounds are used as a monotherapy or used in conjunction with oralanti-diabetic agents.

The term “GLP-1 compounds” refers to GLP-1(7-37)OH and GLP-1(7-36)NH₂and analogs and derivatives thereof. GLP-1 compounds also includeExendin-3 and Exendin-4 and analogs and derivatives thereof. Any ofthese GLP-1 compounds may need further modification or be formulatedsuch that blood plasma levels are maintained for extended time periodsfollowing a single dose. GLP-1 peptides can be made by a variety ofmethods known in the art such as solid-phase synthetic chemistry,purification of GLP-1 molecules from natural sources, recombinant DNAtechnology, or a combination of these methods. For example, methods forpreparing GLP-1 peptides are described in U.S. Pat. Nos. 5,118,666,5,120,712, 5,512,549, 5,977,071, and 6,191,102. As is the custom in theart, the N-terminal residue of a GLP-1 compound is represented asposition 7.

The two naturally occurring truncated GLP-1 peptides are represented informula I, SEQ ID NO: 1.

Formula I, SEQ ID NO:1 7   8   9   10  11  12  13  14  15  16  17His-Ala-Glu-Gly-Thr-Phe-Thr-Ser-Asp-Val-Ser-18  19  20  21  22  23  24  25  26  27  28Ser-Tyr-Leu-Glu-Gly-Gln-Ala-Ala-Lys-Glu-Phe-29  30  31  32  33  34  35  36  37 Ile-Ala-Trp-Leu-Val-Lys-Gly-Arg-Xaawherein:

-   Xaa at position 37 is Gly, or —NH₂.

Preferably, a GLP-1 compound has the amino acid sequence of SEQ ID NO. 1or is modified so that from one, two, three, four or five amino acidsdiffer from SEQ ID NO: 1.

Some GLP-1 compounds known in the art include, for example, GLP-1(7-34)and GLP-1(7-35), GLP-1(7-36), Gln⁹-GLP-1(7-37), D-Gln⁹-GLP-1(7-37),Thr¹⁶-Lys¹⁸-GLP-1(7-37), and Lys¹⁸-GLP-1(7-37). GLP-1 compounds such asGLP-1(7-34) and GLP-1(7-35) are disclosed in U.S. Pat. No. 5,118,666,herein incorporated by reference. Other known biologically active GLP-1analogs are disclosed in U.S. Pat. Nos. 5,977,071; 5,545,618; 5,705,483;5,977,071; 6,133,235: and Adelhorst, et al., J. Biol. Chem. 269:6275(1994).

GLP-1 compounds also include polypeptides in which one or more aminoacids have been added to the N-terminus and/or C-terminus ofGLP-1(7-37)OH, or fragments or analogs thereof. Preferably from one tosix amino acids are added to the N-terminus and/or from one to eightamino acids are added to the C-terminus of GLP-1(7-37)OH. It ispreferred that GLP-1 compounds of this type have up to about thirty-nineamino acids. The amino acids in the “extended” GLP-1 compounds aredenoted by the same number as the corresponding amino acid inGLP-1(7-37)OH. For example, the N-terminal amino acid of a GLP-1compound obtained by adding two amino acids to the N-terminus ofGLP-1(7-37)OH is at position 5; and the C-terminal amino acid of a GLP-1compound obtained by adding one amino acid to the C-terminus ofGLP-1(7-37)OH is at position 39. Amino acids 1-6 of an extended GLP-1compound are preferably the same as or a conservative substitution ofthe amino acid at the corresponding position of GLP-1(1-37)OH. Aminoacids 38-45 of an extended GLP-1 compound are preferably the same as ora conservative substitution of the amino acid at the correspondingposition of Exendin-3 or Exendin-4. The amino acid sequence of Exendin-3and Exendin-4 are represented in formula II, SEQ ID NO: 2.

SEQ ID NO: 2 7   8   9   10  12  12  13  14  15  16  17His-Xaa-Xaa-Gly-Thr-Phe-Thr-Ser-Asp-Leu-Ser18  19  20  21  22  23  24  25  26  27  28Lys-Gln-Met-Glu-Glu-Glu-Ala-Val-Arg-Leu-Phe-29  30  31  32  33  34  35  36  37  38  39Ile-Glu-Trp-Leu-Lys-Asn-Gly-Gly-Pro-Ser-Ser- 40  41  42  43  44  45Gly-Ala-Pro-Pro-Pro-Serwherein:

-   Xaa at position 8 is Ser or Gly; and-   Xaa at position 9 is Asp or Glu;

As used herein, a conservative substitution is the replacement of anamino acid with another amino acid that has the same net electroniccharge and approximately the same size and shape. Amino acids withaliphatic or substituted aliphatic amino acid side chains haveapproximately the same size when the total number carbon and heteroatomsin their side chains differs by no more than about four. They haveapproximately the same shape when the number of branches in the theirside chains differs by no more than one. Amino acids with phenyl orsubstituted phenyl groups in their side chains are considered to haveabout the same size and shape.

A preferred group of GLP-1 compounds is comprised of GLP-1 analogs offormula III (SEQ ID NO: 3):

Formula III (SEQ ID NO: 3) 7   8   9   10  11  12  13  14  15  16  17Xaa-Xaa-Xaa-Gly-Xaa-Xaa-Thr-Xaa-Asp-Xaa-Xaa-18  19  20  21  22  23  24  25  26  27  28Xaa-Xaa-Xaa-Xaa-Xaa-Xaa-Xaa-Xaa-Xaa-Xaa-Phe-29  30  31  32  33  34  35  36  37  38  39Ile-Xaa-Xaa-Xaa-Xaa-Xaa-Xaa-Xaa-Xaa-Xaa-Xaa- 40  41  42  43  44  45Xaa-Xaa-Xaa-Xaa-Xaa-Xaawherein:

-   Xaa at position 7 is: L-histidine, D-histidine, desamino-histidine,    2-amino-histidine, β-hydroxy-histidine, homohistidine,    α-fluoromethyl-histidine or α-methyl-histidine;

Xaa at position 8 is Ala, Gly, Ser, Thr, Leu, Ile, Val, Glu, Asp, orLys; Xaa at position 9 is Glu, Asp, Lys, Thr, Ser, Arg, Trp, Phe, Tyr,or His; Xaa at position 11 is Thr, Ala, Gly, Ser, Leu, Ile, Val, Glu,Asp, Arg, His, or Lys; Xaa at position 14 is Ser, Ala, Gly, Thr, Leu,Ile, Val, Glu, Asp, or Lys; Xaa at position 12 is His, Trp, Phe, or TyrXaa at position 16 is Val, Ala, Gly, Ser, Thr, Leu, Ile, Tyr, Glu, Asp,Trp, His, Phe, or Lys; Xaa at position 17 is Ser, Ala, Gly, Thr, Leu,Ile, Val, Glu, Asp, or Lys; Xaa at position 18 is Ser, Ala, Gly, Thr,Leu, Ile, Val, Glu, Asp, His, Pro, Arg, or Lys; Xaa at position 19 isTyr, Phe, Trp, Glu, Asp, Gly, Gln, Asn, Arg, Cys, or Lys; Xaa atposition 20 is Leu, Ala, Gly, Ser, Thr, Ile, Val, Glu, Asp, Met, or Lys;Xaa at position 21 is Glu, Asp, or Lys; Xaa at position 22 is Gly, Ala,Ser, Thr, Leu, Ile, Val, Glu, Asp, or Lys; Xaa at position 23 is Gln,Asn, Arg, Glu, Asp, His, or Lys; Xaa at position 24 is Ala, Gly, Ser,Thr, Leu, Ile, Val, Arg, Glu, Asp, or Lys; Xaa at position 25 is Ala,Gly, Ser, Thr, Leu, Ile, Val, Glu, Asp, or Lys; Xaa at position 26 isLys, Arg, Gln, Glu, Asp, Trp, Tyr, Phe, or His; Xaa at position 27 isGlu, Asp, Ala, His, Phe, Tyr, Trp, Arg, Leu, or Lys; Xaa at position 30is Ala, Gly, Ser, Thr, Leu, Ile, Val, Glu, Asp, His, or Lys; Xaa atposition 31 is Trp, Phe, Tyr, Glu, Asp, Ser, Thr, Arg, or Lys; Xaa atposition 32 is Leu, Gly, Ala, Ser, Thr, Ile, Val, Glu, Asp, or Lys; Xaaat position 33 is Val, Gly, Ala, Ser, Thr, Leu, Ile, Glu, Asp, Arg, orLys; Xaa at position 34 is Lys, Arg, Glu, Asp, Asn, or His; Xaa atposition 35 is Gly, Ala, Ser, Thr, Leu, Ile, Val, Glu, Asp, Arg, Trp,Tyr, Phe, Pro, His, or Lys; Xaa at position 36 is Arg, Lys, Glu, Asp,Thr, Ser, Trp, Tyr, Phe, Gly, or His; Xaa at position 37 is Gly, Ala,Ser, Thr, Leu, Ile, Val, Glu, Asp, His, Lys, Arg, Trp, Tyr, Phe,Gly-Pro, Gly- Pro-NH₂, —NH₂ or is deleted; Xaa at position 38 is Arg,Lys, Glu, Asp, Ser, or His, or is deleted; Xaa at position 39 is Arg,Lys, Glu, Asp, Ser, or His, or is deleted; Xaa at position 40 is Asp,Glu, Gly, or Lys, or is deleted; Xaa at position 41 is Phe, Trp, Tyr,Glu, Asp, Ala, or Lys, or is deleted; Xaa at position 42 is Pro, Lye,Glu, or Asp, or is deleted; Xaa at position 43 is Glu, Asp, Pro, or Lys,or is deleted; Xaa at position 44 is Glu, Asp, Pro, or Lys, or isdeleted; and Xaa at position 45 is Val, Glu, Asp, Ser, or Lys, or isdeleted, ora C-1-6-ester, or amide, or C-1-6-alkylamide, or C-1-6-dialkylamidethereof; provided that when the amino acid at position 37, 38, 39, 40,41, 42, 43, or 44 is deleted, then each amino acid downstream of thatamino acid is also deleted. It is preferred that the analogs encompassedby formula III, have not more than six amino acids that differ from thecorresponding amino acids in GLP-1(7-37)OH, GLP-1(7-36)NH₂, Exendin-3,or Exendin-4. It is more preferred that the analogs encompassed byformula III have between one and five amino acids that differ from thecorresponding amino acids in GLP-1(7-37)OH, GLP-1(7-36)NH₂, Exendin-3,or Exendin-4.

Another preferred group of GLP-1 compounds is comprised of GLP-1 analogsof formula IV (SEQ ID NO: 4):

formula IV (SEQ ID NO: 4)His-Xaa₈-Glu-Gly-Xaa₁₁-Xaa₁₂-Thr-Ser-Asp-Xaa₁₆-Ser-Ser-Tyr-Leu-Glu-Xaa₂₂-Xaa₂₃-Xaa₂₄-Ala-Xaa₂₆-Xaa₂₇-Phe-Ile-Ala-Xaa₃₁-Leu-Xaa₃₃-Xaa₃₄-Xaa₃₅-Xaa₃₆-R wherein: Xaa₈ is: Gly, Ala,Val, Leu, Ile, Ser, or Thr; Xaa₁₁ is: Asp, Glu, Arg, Thr, Ala, Lys, orHis; Xaa₁₂ is: His, Trp, Phe, or Tyr; Xaa₁₆ is: Leu, Ser, Thr, Trp, His,Phe, Asp, Val, Glu, or Ala; Xaa₂₂ is: Gly, Asp, Glu, Gln, Asn, Lys, Arg,Cys, or Cysteic Acid; Xaa₂₃ is: His, Asp, Lys, Glu, or Gln; Xaa₂₄ is:Glu, His, Ala, or Lys; Xaa₂₆ is: Asp, Lys, Glu, or His; Xaa₂₇ is: Ala,Glu, His, Phe, Tyr, Trp, Arg, or Lys; Xaa₃₀ is: Ala, Glu, Asp, Ser, orHis; Xaa₃₃ is: Asp, Arg, Val, Lys, Ala, Gly, or Glu; Xaa₃₄ is: Glu, Lys,or Asp; Xaa₃₅ is: Thr, Ser, Lys, Arg, Trp, Tyr, Phe, Asp, Gly, Pro, His,or Glu; Xaa₃₆ is: Arg, Glu, or His; R is: Lys, Arg, Thr, Ser, Glu, Asp,Trp, Tyr, Phe, His, —NH₂, Gly, Gly-Pro, or Gly-Pro-NH₂,It is preferred that the analogs encompassed by formula IV, have notmore than six amino acids that differ from the corresponding amino acidsin GLP-1(7-37)OH, or GLP-1(7-36)NH₂. It is more preferred that theanalogs encompassed by formula IV have between one and five amino acidsthat differ from the corresponding amino acids in GLP-1(7-37)OH, orGLP-1(7-36)NH₂.

Another preferred group of GLP-1 compounds is comprised of GLP-1 analogsof formula V (SEQ ID NO: 5):

formula III (SEQ ID NO: 5)His-Xaa₈-Glu-Gly-Thr-Xaa₁₂-Thr-Ser-Asp-Xaa₁₆-Ser-Ser-Tyr-Leu-Glu-Xaa₂₂-Xaa₂₃-Ala-Ala-Xaa₂₆-Glu-Phe-Ile-Xaa₃₀-Trp-Leu-Val-Lys-Xaa₃₅-Arg-R wherein: Xaa₈ is: Gly, Ala, Val,Leu, Ile, Ser, or Thr; Xaa₁₂ is: His, Trp, Phe, or Tyr; Xaa₁₆ is: Leu,Ser, Thr, Trp, His, Phe, Asp, Val, Glu, or Ala; Xaa₂₂ is: Gly, Asp, Glu,Gln, Asn, Lys, Arg, Cys, or Cysteic Acid; Xaa₂₃ is: His, Asp, Lys, Glu,or Gln; Xaa₂₆ is: Asp, Lys, Glu, or His; Xaa₃₀ is: Ala, Glu, Asp, Ser,or His; Xaa₃₅ is: Thr, Ser, Lys, Arg, Trp, Tyr, Phe, Asp, Gly, Pro, His,or Glu; R is: Lys, Arg, Thr, Ser, Glu, Asp, Trp, Tyr, Phe, His, —NH₂,Gly, Gly-Pro, or Gly-Pro-NH₂, or is deleted.It is preferred that the analogs encompassed by formula V, have not morethan six amino acids that differ from the corresponding amino acids inGLP-1(7-37)OH, or GLP-1(7-36)NH₂. It is more preferred that the analogsencompassed by formula V have between one and five amino acids thatdiffer from the corresponding amino acids in GLP-1(7-37)OH orGLP-1(7-36)NH₂.

Another preferred group of GLP-1 compounds is comprised of GLP-1 analogsof formula VI (SEQ ID NO: 6):

formula VI (SEQ ID NO: 6)His-Xaa₈-Glu-Gly-Thr-Phe-Thr-Ser-Asp-Val-Ser-Ser-Tyr-Leu-Glu-Xaa₂₂-Xaa₂₃-Ala-Ala-Lys-Xaa₂₇-Phe-Ile-Xaa₃₀-Trp-Leu-Val-Lys-Gly-Arg-R wherein: Xaa₈ is: Gly, Ala, Val, Leu,Ile, Ser, or Thr; Xaa₂₂ is: Gly, Asp, Glu, Gln, Asn, Lys, Arg, Cys, orCysteic Acid; Xaa₂₃ is: His, Asp, Lys, Glu, or Gln; Xaa₂₇ is: Ala, Glu,His, Phe, Tyr, Trp, Arg, or Lys Xaa₃₀ is: Ala, Glu, Asp, Ser, or His; Ris: Lys, Arg, Thr, Ser, Glu, Asp, Trp, Tyr, Phe, His, —NH₂, Gly,Gly-Pro, or Gly-Pro-NH₂, or is deleted.

Another preferred group of GLP-1 compounds is comprised of GLP-1 analogsof formula VII (SEQ ID NO. 7):

(SEQ ID NO: 7) Xaa₇-Xaa₈-Glu-Gly-Thr-Phe-Thr-Ser-Asp-Val-Ser-Ser-Tyr-Leu-Glu-Xaa₂₂-Gln-Ala-Ala-Lys-Glu-Phe-Ile-Ala-Trp-Leu-Val-Lys-Gly-Arg-Rwherein:

Xaa₇ is L-histidine, D-histidine, desamino-histidine, 2amino-histidine,β-hydroxy-histidine, homohistidine, α-fluoromethyl-histidine orα-methyl-histidine;

Xaa₈ is glycine, alanine, valine, leucine, isoleucine, serine orthreonine. Preferably, Xaa₈ is glycine, valine, leucine, isoleucine,serine or threonine;

Xaa₂₂ is aspartic acid, glutamic acid, glutamine, asparagine, lysine,arginine, cysteine, or cysteic acid.

R is —NH₂ or Gly(OH).

Most preferred GLP-1 compounds of formula I, II, III, IV, V, and VIcomprise GLP-1 analogs wherein the backbone for such analogs orfragments contains an amino acid other than alanine at position 8(position 8 analogs). Preferred amino acids at position 8 are glycine,valine, leucine, isoleucine, serine, threonine, or methionine and morepreferably are valine or glycine.

Other preferred GLP-1 compounds are GLP-1 analogs that have the sequenceof GLP-1(7-37)OH except that the amino acid at position 8 is preferablyglycine, valine, leucine, isoleucine, serine, threonine, or methionineand more preferably valine or glycine and position 22 is glutamic acid,lysine, aspartic acid, or arginine and more preferably glutamic acid orlysine.

Other preferred GLP-1 compounds are GLP-1 analogs that have the sequenceof GLP-1(7-37)OH except that the amino acid at position 8 is preferablyglycine, valine, leucine, isoleucine, serine, threonine, or methionineand more preferably valine or glycine and position 30 is glutamic acid,aspartic acid, serine, or histidine and more preferably glutamic acid.

Other preferred GLP-1 compounds are GLP-1 analogs that have the sequenceof GLP-1(7-37)OH except that the amino acid at position 8 is preferablyglycine, valine, leucine, isoleucine, serine, threonine, or methionineand more preferably valine or glycine and position 37 is histidine,lysine, arginine, threonine, serine, glutamic acid, aspartic acid,tryptophan, tyrosine, phenylalanine and more preferably histidine.

Other preferred GLP-1 compounds are GLP-1 analogs that have the sequenceof GLP-1(7-37)OH except that the amino acid at position 8 is preferablyglycine, valine, leucine, isoleucine, serine, threonine, or methionineand more preferably valine or glycine and position 22 is glutamic acid,lysine, aspartic acid, or arginine and more preferably glutamic acid orlysine and position 23 is lysine, arginine, glutamic acid, asparticacid, and histidine and more preferably lysine or glutamic acid.

Other preferred GLP-1 compounds are GLP-1 analogs that have the sequenceof GLP-1(7-37)OH except that the amino acid at position 8 is preferablyglycine, valine, leucine, isoleucine, serine, threonine, or methionineand more preferably valine or glycine and position 22 is glutamic acid,lysine, aspartic acid, or arginine and more preferably glutamic acid orlysine and position 27 is alanine, lysine, arginine, tryptophan,tyrosine, phenylalanine, or histidine and more preferably alanine.

In the nomenclature used herein to describe GLP-1 compounds, thesubstituting amino acid and its position is indicated prior to theparent structure. For example Val⁸-GLP-1(7-37)OH designates a GLP-1compound in which the alanine normally found at position 8 inGLP-1(7-37)OH (formula I, SEQ ID NO:1) is replaced with valine.

Other preferred GLP-1 compounds include: Val⁸-GLP-1(7-37)OH,Gly⁸-GLP-1(7-37)OH, Glu²²-GLP-1(7-37)OH, Asp²²-GLP-1(7-37)OH,Arg²²-GLP-1(7-37)OH, Lys²²-GLP-1(7-37)OH, Cys²²-GLP-1(7-37)OH,Val⁸-Glu²²-GLP-1(7-37)OH, Val⁸-Asp²²-GLP-1(7-37)OH,Val⁸-Arg²²-GLP-1(7-37)OH, Val⁸-Lys²²-GLP-1(7-37)OH,Val⁸-Cys²²-GLP-1(7-37)OH, Gly⁸-Glu²²-GLP-1(7-37)OH,Gly⁸-Asp²²-GLP-1(7-37)OH, Gly⁸-Arg²²-GLP-1(7-37)OH,Gly⁸-Lys²²-GLP-1(7-37)OH, Gly⁸-Cya²²-GLP-1(7-37)OH,Glu²²-GLP-1(7-36)NH₂, Asp²²-GLP-1(7-36)NH₂, Arg²²-GLP-1(7-36)NH₂,Lys²²-GLP-1(7-36)NH₂, Cys²²-GLP-1(7-36)NH₂, Val⁸-Glu²²-GLP-1(7-36)NH₂,Val⁸-Asp²²-GLP-1(7-36)NH₂, Val⁸-Arg²²-GLP-1(7-36)NH₂,Val⁸-Lys²²-GLP-1(7-36)NH₂, Val⁸-Cys²²-GLP-1(7-36)NH₂,GLY⁸-Glu²²-GLP-1(7-36)NH₂, Gly⁸-Asp²²-GLP-1(7-36)NH₂,Gly⁸-Arg²²-GLP-1(7-36)NH₂, Gly⁸-Lys²²-GLP-1(7-36)NH₂,Gly⁸-Cys²²-GLP-1(7-36)NH₂, Lys²³-GLP-1(7-37)OH,Val⁸-Lys²³-GLP-1(7-37)OH, Gly⁸-Lys²³-GLP-1(7-37)OH, His²⁴-GLP-1(7-37)OH,Val⁸-His²⁴-GLP-1(7-37)OH, Gly⁸-His²⁴-GLP-1(7-37)OH, Lys²⁴-GLP-1(7-37)OH,Val⁸-Lys²⁴-GLP-1(7-37)OH, Gly⁸-Lys²³-GLP-1(7-37)OH, Glu³⁰-GLP-1(7-37)OH,Val⁸-Glu³⁰-GLP-1(7-37)OH, Gly⁸-Glu³⁰-GLP-1(7-37)OH, Asp³⁰-GLP-1(7-37)OH,Val⁸-Asp³⁰-GLP-1(7-37)OH, Gly⁸-Asp³⁰-GLP-1(7-37)OH, Gln³⁰-GLP-1(7-37)OH,Val⁸-Gln³⁰-GLP-1(7-37)OH, Gly⁸-Gln³⁰-GLP-1(7-37)OH, Tyr³⁰-GLP-1(7-37)OH,Val⁸-Tyr³⁰-GLP-1(7-37)OH, Gly⁸-Tyr³⁰-GLP-1(7-37)OH, Ser³⁰-GLP-1(7-37)OH,Val⁸-Ser³⁰-GLP-1(7-37)OH, Gly⁸-Ser³⁰-GLP-1(7-37)OH, His³⁰-GLP-1(7-37)OH,Val⁸-His³⁰-GLP-1(7-37)OH, Gly⁸-His³⁰-GLP-1(7-37)OH, Glu³⁴-GLP-1(7-37)OH,Val⁸-Glu³⁴-GLP-1(7-37)OH, Gly⁸-Glu³⁴-GLP-1(7-37)OH, Ala³⁴-GLP-1(7-37)OH,Val⁸-Ala³⁴-GLP-1(7-37)OH, Gly⁸-Ala³⁴-GLP-1(7-37)OH, Gly³⁴-GLP-1(7-37)OH,Val⁸-Gly³⁴-GLP-1(7-37)OH, Gly⁸-Gly³⁴-GLP-1(7-37)OH, Ala³⁵-GLP-1(7-37)OH,Val⁸-Ala³⁵-GLP-1(7-37)OH, Gly⁸-Ala³⁵-GLP-1(7-37)OH, Lys³⁵-GLP-1(7-37)OH,Val⁸-Lys³⁵-GLP-1(7-37)OH, Gly⁸-Lys³⁵-GLP-1(7-37)OH, His³⁵-GLP-1(7-37)OHVal⁸-His³⁵-GLP-1(7-37)OH, Gly⁸-His³⁵-GLP-1(7-37)OH, Pro³⁵-GLP-1(7-37)OH,Val⁸-Pro³⁵-GLP-1(7-37)OH, Gly⁸-Pro³⁵-GLP-1(7-37)OH, Glu³⁵-GLP-1(7-37)OHVal⁸-Glu³⁵-GLP-1(7-37)OH, Gly⁸-Glu³⁵-GLP-1(7-37)OH,Val⁸-Ala²⁷-GLP-1(7-37)OH, Val⁸-His³⁷-GLP-1(7-37)OH,Val⁸-Glu²²-Lys²³-GLP-1(7-37)OH, Val⁸-Glu²²-Glu²³-GLP-1(7-37)OH,Val⁸-Glu²²-Ala²⁷-GLP-1(7-37)OH, Val⁸-Gly³⁴-Lys³⁵-GLP-1(7-37)OH,Val⁸-His³⁷-GLP-1(7-37)OH, and Gly⁸-His³⁷-GLP-1(7-37)OH.

More preferred GLP-1 compounds are Val⁸-GLP-1(7-37)OH,Gly⁸-GLP-1(7-37)OH, Glu²²-GLP-1(7-37)OH, Lys²²-GLP-1(7-37)OH,Val⁸-Glu²²-GLP-1(7-37)OH, Val⁸-Lys²²-GLP-1(7-37)OH,Gly⁸-Glu²²-GLP-1(7-37)OH, Gly⁸-Lys²²-GLP-1(7-37)OH,Glu²²-GLP-1(7-36)NH₂, Lys²²-GLP-1(7-36)NH₂, Val⁸-Glu²²-GLP-1(7-36)NH₂,Val⁸-Lys²²-GLP-1(7-36)NH₂, Gly⁸-Glu²²-GLP-1(7-36)NH₂,Gly⁸-Lys²²-GLP-1(7-36)NH₂, Val⁸-His³⁷-GLP-1(7-37)OH,Gly⁸-His³⁷-GLP-1(7-37)OH, Arg³⁴-GLP-1(7-36)NH₂, and Arg³⁴-GLP-1(7-37)OH.

A GLP-1 compound also includes a “GLP-1 derivative” which is defined asa molecule having the amino acid sequence of GLP-1 or of a GLP-1 analog,but additionally having chemical modification of one or more of itsamino acid side groups, α-carbon atoms, terminal amino group, orterminal carboxylic acid group. A chemical modification includes, but isnot limited to, adding chemical moieties, creating new bonds, andremoving chemical moieties.

The GLP-1 compound used for the chronic treatment regimen may requiremodification or formulation so that blood plasma levels are maintainedin the claimed efficacious range for extended time periods. Variousmeans can be employed to achieve a protracted time action including, forexample, the incorporation of GLP-1 compounds into suspended amorphousor crystalline particles wherein the GLP-1 compound is complexed withzinc or protamine and slowly solubilizes upon administration. Anothermeans includes derivatizing a GLP-1 compound such that it binds plasmaalbumin and slowly dissociates over time. In addition, depotformulations wherein an bioadsorbable polymer is used to providesustained release over time are also suitable for use in the presentinvention.

For example, GLP-1 compound can be incorporated into zinc crystals whichhave a protracted time action by dissolving the selected GLP-1 peptidein a glycine-free solution at a pH of about 9.5 to about 11.5. This“alkaline normalization” step appears to reduce the content of β-sheetconformation in the peptide and enhance the α-helix conformation that isimportant for solubility and bioavailability of some GLP-1 compounds.This step also serves to maintain the peptide in a preferred α-helixconformation prior to the subsequent process step. This key step thus“normalizes” variation in bulk lots of the peptide into a morereproducible, homogenous solution.

Preferably, the peptide concentration in the alkaline normalizationsolution is greater than 5 mg/mL. More preferably, the concentration isabout 10 mg/mL to about 30 mg/mL. Other ranges of preferredconcentration of dissolved peptide are about 5 mg/mL to about 25 mg/mL,about 8 mg/mL to about 25 mg/mL and about 10 mg/mL to about 20 mg/mL.The most preferred concentration is about 15 mg/mL.

Preferably, an aqueous alkaline solution comprising only water and abase such as NaOH, KOH or ammonium hydroxide is employed to dissolve thepeptide. A more preferred base is NaOH.

Preferably, the pH of the alkaline normalization step is about 10.0 toabout 11.0. More preferably, the pH is about 10.5. The alkaline solutioncomprising the dissolved peptide may be allowed to sit quiescently for aperiod of about 5 minutes to about 3 hours at ambient temperature,which, although it is not to be construed as a limitation, is generallybetween about 20° C. and about 25° C. The alkaline solution may also begently stirred. More preferably, the dissolved alkaline peptide solutionwill sit quiescently for about 1 hour at ambient temperature. Oneskilled in the art will recognize that combinations of pH, time,temperature and stirring conditions for this step can be readilyestablished for each peptide that ensures “normalization” of the peptideconformation is complete yet avoids or minimizes chemical degradationthat may occur to the peptide.

The next step in the process for preparing crystals of a selectedpeptide is the addition of glycine. Amino acids such as glycine bindzinc ions which also bind very tightly to the histidine residue(s) in apeptide. Thus, competition for zinc binding may play a role in theformation of peptide crystals, as well as in the stability of subsequentcrystalline compositions. The glycine added to the alkaline peptidesolution may be in a solid form or in a stock solution. Preferably,glycine is added as a solid. Preferably, the added glycine is infree-base form. Preferably, the resulting concentration of glycine inthe alkaline peptide solution is about 5 mM to about 250 mM. Ranges ofmore preferred glycine concentration are about 10 mM to about 150 mM,about 20 mM to about 100 mM, about 40 mM to about 80 mM and about 55 mMto about 65 mM. Most preferably, the glycine concentration is about 60mM.

Optionally, the pH of the alkaline peptide solution may be readjustedafter the addition of the glycine. If the pH is adjusted, it ispreferably adjusted to a pH between about 9.0 and about 11.0. Morepreferably, it is adjusted to a pH between about 9.2 and about 9.8. Mostpreferably, it is adjusted to about pH 9.5.

Optionally, the alkaline peptide solution with added glycine may befiltered. Filtration is recommended if any evidence of undissolvedparticles, dust or lint is apparent in the solution. If desired, this isalso a good place in the process at which the solution can be sterilizedby performing an aseptic filtration step. Preferably, the filtrationwill be conducted using a sterile non-pyrogenic filter havinglow-protein binding and a pore size of 0.45 μm or less. Preferably, thefilter is a sterile non-pyrogenic, low-protein binding filter of poresize 0.22 μm or less. More preferably, the filter is a sterile 0.22 μmMillex® filter (Millipore Corporation, Waltham, Mass., USA).

The next step in the process of forming crystals is addition to thealkaline peptide solution of about 2% to about 20% of the total finalvolume of an alcohol selected from the group consisting of ethanol andisopropanol, and about 0.5 moles to about 2.5 moles of zinc per mole ofthe peptide. The zinc and ethanol may be added in a single aqueous stocksolution or may be added separately in one or more steps in any order.Preferably, the alcohol is added before the zinc is added.

Preferably, the added alcohol represents, by volume, about 2% to about20% of the total final volume of the alkaline peptide-zinc-alcoholsolution. More preferably, the alcohol represents about 5% to about 15%of the total final volume. More preferably, the alcohol represents about6% to about 12% of the total final volume. Most preferably, the alcoholrepresents about 9% of the total final volume. Preferably, the alcoholis ethanol.

The zinc added at this stage refers to the zinc ion. The zinc may beadded in a variety of forms, but a zinc oxide solution acidified withdilute HCl and salt forms such as zinc acetate or zinc chloride arepreferred. More preferred is a zinc oxide solution acidified with diluteHCl.

Preferably, 1.0 moles to about 2.25 moles of zinc per mole of thepeptide is added in this process step. Other preferred ranges of zincaddition include 1.1 to 2.0 moles of zinc per mole of the peptide, 1.3to 1.7 moles per mole of peptide, and 1.4 to 1.6 moles per mole ofpeptide. Most preferably, about 1.5 moles of zinc per mole of peptide isadded.

Preferably, the solution comprising zinc that is added to the peptidesolution is added slowly and/or in small increments, which minimizes thelocalized precipitation of peptide and/or zinc complexes that may format the site of addition. More preferably, glycine is also a component ofthe solution comprising zinc that is being added at this step. Forexample, a zinc-glycine solution may be prepared by dissolving zincoxide in dilute HCl to a pH of about 1.6 and then adding solid glycine.A sufficient quantity of glycine is added to raise the pH of thesolution to between about pH 2 and about pH 3. The pH of thezinc-glycine solution may be raised further using, for example, diluteNaOH. A preferred pH range of the zinc-glycine solution is about pH 4.0to about pH 6.0. A more preferred pH range of the zinc-glycine solutionis about pH 5.0 to about pH 5.5. As noted earlier, glycine has a bindingaffinity for zinc that may compete with zinc binding to the peptide.Thus, the presence of glycine in the solution comprising zinc that isbeing added to the composition allows the zinc solution to be added morequickly because localized precipitation problems are minimized. Inaddition, having a zinc-glycine solution above pH 2.0, and preferablyabout pH 4.0 to about pH 6.0, allows the solution to be sterile filteredusing filters that are rated by their manufacturers to handle, forexample, pH 2-10 solutions, prior to its introduction into a sterilepeptide composition. Preferably, the zinc-glycine solution comprisesabout 50 mM to about 70 mM glycine and about 20 mM to about 200 mM zinc.

The last steps in the initial crystallization of a selected peptide areadjusting the pH of the solution to between about pH 7.5 and about pH10.5 and allowing crystals of the peptide to form. Preferred reagentsolutions useful for adjusting the pH of the solution include diluteHCl, dilute acetic acid and dilute NaOH.

Preferred pH ranges for crystallization of selected peptides includeabout pH 8.0 to about pH 10.0, about pH 7.5 to about pH 9.5, about pH8.5 to about pH 9.2, about pH 9.0 to about pH 9.5, about pH 7.5 to aboutpH 8.5, about pH 8.7 to about pH 9.5, and about pH 9.2 to about pH 10.0.

One skilled in the art will recognize that the preferred pH ofcrystallization will depend on many factors, including the nature of thepeptide and its concentration, the alcohol concentration, the zincconcentration, the ionic strength of the solution and the temperature ofcrystallization. By way of illustration, the peptideVal⁸-Glu³⁰-GLP-1(7-37)OH produced crystals at only select ethanol andzinc concentrations at a pH range of about 7.7 to about 8.1, whereas thepeptide Val⁸-His³⁷-GLP-1(7-37)OH produced crystals over a broad range ofzinc and ethanol concentrations at a pH range of about 9.8 to about10.4.

The skilled artisan will further recognize that, for a given set ofconditions, a preferred manner of determining the optimal pH ofcrystallization is to determine it empirically, that is, to slowly addthe acidification solution, preferably dilute HCl or dilute acetic acid,in small increments, and observe what happens after each increment isadded. Generally, small quantities of localized zones of precipitationwill occur at the spot of addition of the acidic solution. When gentleswirling takes increasingly longer periods of time to completelyredissolve the precipitation, that is the best time to stop adding theacid and allow crystallization from the clear or slightly cloudysolution to proceed.

The skilled artisan will further recognize that the pH and temperaturethat one selects for crystallization will have an impact on the speed atwhich the crystallization proceeds, the crystallization yield, and thesize and homogeneity of the crystals formed. Preferably, the pH ofcrystallization for the selected peptides is about pH 8.0 to about pH10. More preferably, the pH is about 8.7 to about 9.5. Other ranges ofpreferred pH of crystallization are about 8.8 to about 9.3, about 9.0 toabout 9.5, and about 8.5 to about 9.3. Most preferably, thecrystallization is conducted at about pH 9.1.

Preferably, the temperature of crystallization is about 10° C. to about30° C. More preferably, the temperature of crystallization is about 15°C. to about 28° C. Most preferably, the temperature of crystallizationis ambient temperature, or about 20° C. to about 25° C.

Preferably, the crystallization step described above is complete, thatis, 90% or more of the peptide is precipitated in predominantlycrystalline form, in about 3 hours to about 72 hours. More preferably,the crystallization is complete in about 10 hours to about 48 hours.Most preferably, the crystallization is complete in about 16 hours toabout 26 hours. Completion of crystallization may be determined by avariety of means, including HPLC analysis of the peptide present in analiquot of the composition. Method 5 herein describes one such protocolthat may be employed.

Preferably, the crystals produced according to the steps of the processdescribed above are thin plate crystals. The crystals produced by theprocess may be examined by microscopy.

Pharmaceutical compositions comprising crystals of a GLP-1 peptideprepared as described above may be prepared by adding suitable,pharmaceutically acceptable excipients to the crystal suspension in theoriginal mother liquor. Alternatively, the crystals may be isolated byfiltration, gentle centrifugation or other means of phase separation,and used in a variety of ways to prepare pharmaceutically acceptablecompositions. The skilled artisan will recognize suitable procedures andexcipients useful for preparing such pharmaceutical compositions.

The following process starts with the crystals and original motherliquor from the initial crystallization stage and continues with thepreparation of a stable pharmaceutical composition.

To prepare a stable pharmaceutical composition of crystals of a selectedpeptide, the pH of the suspension of crystals in their complete originalmother liquor, or portion thereof, is lowered to a pH value at which 97%or more of the peptide becomes insoluble. Preferably, this part of theprocess begins within a few hours after the initial crystallization isdetermined to be complete. Preferably, the pH is lowered using a dilutesolution of HCl or acetic acid wherein the acidic solution is addedslowly and in incremental portions. The skilled artisan will recognizethat the preferred pH at which this second stage of crystallizationshould occur will depend on many factors, including the nature of thepeptide and its concentration, the alcohol concentration, the zincconcentration, the ionic strength of the suspension and the temperatureof crystallization. Preferably, the pH is about 0.2 to 2.0 pH unitslower than the pH at which the initial crystallization proceeded. Morepreferably, the pH is about 0.5 to about 1.5 pH units lower, and mostpreferably, the pH is about 0.8 to 1.3 pH units lower than the pH atwhich the initial crystallization proceeded. The temperature of thissecond stage of crystallization is preferably ambient temperature, orabout 20° C. to about 25° C. For the peptide Val⁸-GLP-1(7-37)OH, apreferred pH is about 7.5 to about 8.5. A more preferred pH is about 7.8to about 8.2.

Preferably, the pH of a suspension of peptide crystals is lowered to apH at which 98% or more, and more preferably at which 99% or more of thepeptide becomes insoluble in the composition. The additionalprecipitation formed in this second stage of crystallization comprisescrystals. Preferably, the additional precipitation formed in this secondstage of crystallization will be predominantly crystals of comparablemorphology and size distribution as those formed in the first stage ofcrystallization.

Preferably, the second stage of crystallization is complete enough, thatis, 97% or more of the peptide is insoluble, to allow the following stepto begin within 30 hours, more preferably within 18 hours, morepreferably within 6 hours and most preferably within 2 hours of when thesecond stage of crystallization started. Quantitation of precipitationyield may be determined by a variety of means, including HPLC analysisof the peptide present in an aliquot of the composition.

The next step in the process to prepare a stable pharmaceuticalcomposition of crystals of a selected peptide is to add apharmaceutically acceptable preservative and a buffer selected from thegroup consisting of TRIS, maleate, phosphate, succinate, glycylglycineand adipate. Optionally, one or more tonicity agents such as sodiumchloride, other salts, glycerin or mannitol may also be added. Thesecomponents may be added as a single solution, as combination solutionsor individually in any order. It is preferred that the preservative isadded last. Of these components, a preferred buffer is selected from thegroup consisting of TRIS and maleate, a preferred preservative ism-cresol and a preferred tonicity agent is sodium chloride. A morepreferred buffer is TRIS.

A preferred quantity of TRIS to add to the crystalline peptidesuspension, if TRIS is the selected buffer, is such that the TRISconcentration in the final composition is about 5 mM to about 40 mM. Amore preferred range of TRIS concentration in the final composition isabout 10 mM to about 20 mM. A most preferred concentration of TRIS inthe final composition is about 15 mM.

A preferred quantity of maleate to add to the crystalline peptidesuspension, if maleate is the selected buffer, is such that the maleateconcentration in the final composition is about 2 mM to about 20 mM. Amore preferred range of maleate concentration in the final compositionis about 5 mM to about 15 mM. A most preferred concentration of maleatein the final composition is about 9 mM.

If sodium chloride is selected to be a component of the peptidecomposition, a preferred quantity to add to the crystalline peptidesuspension is such that the added sodium chloride in the finalcomposition is about 30 mM to about 200 mM. A more preferredconcentration of added sodium chloride in the final composition is 50 mMto about 150 mM. Other ranges of preferred sodium chloride concentrationare about 80 mM to about 120 mM, about 70 mM to about 130 mM, and about90 mM to about 130 mM. A most preferred quantity of added sodiumchloride in a pharmaceutical composition is about 110 mM.

Although any pharmaceutically acceptable preservative may be added tothe crystalline peptide suspension at this point in the process, for acomposition of the present invention a phenolic preservative or benzylalcohol is preferred. Examples of phenolic preservatives include phenol,chlorocresol, m-cresol, o-cresol, p-cresol, ethylparaben, methylparaben,propylparaben, butylparaben, thymol or mixtures thereof. More preferredpreservatives are benzyl alcohol, m-cresol, phenol, methylparaben andmixtures thereof. A most preferred pharmaceutically acceptablepreservative is m-cresol.

A preferred quantity of a pharmaceutically acceptable preservative toadd to a crystalline peptide composition at this point in the process isan amount such that the preservative concentration in the finalcomposition is about 1.0 mg/mL to about 20.0 mg/mL. More preferredranges of concentration of preservative in the final composition areabout 2.0 mg/mL to about 8.0 mg/mL, about 2.5 mg/mL to about 4.5 mg/mLand about 2.0 mg/mL to about 4.0 mg/mL. A most preferred concentrationof preservative in the final composition is about 3.0 mg/mL.

The final step in the process of preparing a stable pharmaceuticalcomposition of crystals of a selected peptide is an adjustment to afinal pH between about 6.0 and about 8.5 and preferably between about pH6.5 and about pH 8.0. Although any of a wide variety of acidificationand/or alkalization reagent solutions may be employed for this pHadjustment, dilute HCl, dilute NaOH and dilute acetic acid arepreferred. More preferred reagent solutions are dilute HCl and diluteNaOH. The preferred pH to which the composition is adjusted will dependto some extent upon the selected peptide, the peptide concentration, theproposed route of administration and the selected buffer.

Preferably, with TRIS as the selected buffer, the pH will be adjusted toa pH between about 6.5 and about 8.5. More preferably, the pH will beadjusted to a pH between about 7.0 and about 7.8, between about 7.2 andabout 7.8, between about 7.5 and about 8.5, or between about 7.0 andabout 8.0. A most preferred pH to which the composition is adjusted whenTRIS is the selected buffer is about 7.5. With maleate as the selectedbuffer, the pH will be adjusted to a pH between about 6.0 and about 7.5.More preferably, the pH will be adjusted to a pH between about 6.4 andabout 7.5, between about 6.4 and about 7.0, or between about 6.0 andabout 7.0. A most preferred pH to which the composition is adjusted whenmaleate is the selected buffer is about 6.5.

Instead of a formulation approach, long acting GLP-1 compounds suitablefor the treatment regimen of the present invention can be derivitized.Derivatization is accomplished by various means. Modifications at aminoacid side groups include, without limitation, acylation of lysines-amino groups, N-alkylation of arginine, histidine, or lysine,alkylation of glutamic or aspartic carboxylic acid groups, anddeamidation of glutamine or asparagine. Modifications of the terminalamino group include, without limitation, the des-amino, N-lower alkyl,N-di-lower alkyl, and N-acyl modifications. Modifications of theterminal carboxy group include, without limitation, the amide, loweralkyl amide, dialkyl amide, and lower alkyl ester modifications.Furthermore, one or more side groups, or terminal groups, may beprotected by protective groups known to the ordinarily-skilled proteinchemist. The α-carbon of an amino acid may be mono- or dimethylated.

Preferred GLP-1 derivatives are achieved through acylation. Using theprinciple of fatty acid derivitization, GLP-1 action is protracted byfacilitating binding to plasma albumin via association of the fatty acidresidue to fatty acid binding sites on albumin in the blood andperipheral tissues. A preferred GLP-1 derivative isArg³⁴Lys²⁶-(N-ε-(γ-Glu(N-α-hexadecanoyl)))-GLP-1(7-37). GLP-1derivatives and methods of making such derivatives are disclosed inKnudsen, et al. (2000) J. Med. Chem. 43:1664-1669. In addition, numerouspublished applications describe derivatives of GLP-1, GLP-1 analogs,Exendin-4, and Exendin-4 analogs. See U.S. Pat. No. 5,512,540,WO96/29342, WO98/08871, WO99/43341, WO99/43708, WO99/43707, WO99/43706,and WO99/43705.

GLP-1 peptides can also be encapsulated using microspheres and thendelivered orally. For example, GLP-1 compounds can be encapsulated intomicrospheres composed of a commercially available, biocompatible,biodegradable polymer, poly(lactide-co-glycolide)-COOH and olive oil asa filler. See Joseph, et al. (2000) Diabetologia 43:1319-1328. Othertypes of microsphere technology is also available commercially such asMedisorb® and Prolease® biodegradable polymers from Alkermes. Medisorb®polymers can be produced with any of the lactide isomers.Lactide:glycolide ratios can be varied between 0:100 and 100:0 allowingfor a broad range of polymer properties. This allows for the design ofdelivery systems and implantable devices with resorption times rangingfrom weeks to months.

Another embodiment of the present invention encompasses articles ofmanufacture for human pharmaceutical use comprising a package insert, acontainer, and said insert describing a treatment regimen which involvesmaintaining plasma levels of a GLP-1 compound with a particular potencywithin a certain range that avoids or minimizes side effects such asnausea and vomiting.

The container used in the present article of manufacture is conventionalin the pharmaceutical arts. Generally, the container is a vial orcartridge, usually made of glass, and accompanying cap, closure, bead,plunger, septum, and/or seal or other such article suitable for use bythe patient or pharmacist. Alternatively, the container is part of a kitconsisting of a cartridge containing dried powder and a syringepre-filled with an appropriate diluent. Other options include thecontainer consisting of a dual chamber cartridge with a bypass thatkeeps the diluent liquid and the dried powder separate from each otheruntil reconstitution is desired. At the time of reconstitution, the dualchamber cartridge permits the diluent liquid to flow into the driedpowder. Preferably, the container is sized to accommodate 0.1 to 100 mL,preferably 0.5 to 25 mL, and more preferably, 5 to 10 mL, even morepreferably 1.5 to 3 mL volumes. Alternatively, the container is ablister, capsule, or blister disc. Other options for the containerinclude a transdermal patch, implantable device, microsphere carriersand other depot delivery systems.

The insert may provide the physician with a choice of several doseswhich result in plasma levels of the GLP-1 compound within the rangesdescribed herein, or preferably the insert will provide the physicianwith a single dose which results in plasma levels of the GLP-1 compoundwithin the ranges described herein.

The package insert provides a description of how to administer apharmaceutical product, along with the safety and efficacy data requiredto allow the physician, pharmacist, and patient to make an informeddecision regarding the use of the product. The package insert generallyis regarded as the label of the pharmaceutical product.

The package insert may provide some or all of the following indicationsor label descriptions:

-   -   1) improved glycemic control in patients inadequately controlled        on single or multiple oral anti-diabetic agents as a monotherapy        or as a combination therapy with single of multiple oral        anti-diabetic agents compared to such agents alone;    -   2) use for patients with inadequately controlled hyperglycemia;    -   3) mean reduction in HbAlc greater than or equal to 0.5%,        preferably greater than or equal to 1% in patients inadequately        controlled on single or multiple oral anti-diabetic agents;    -   4) mean weight gain for patients on monotherapy will be less        than the mean weight gain for patients treated with either a TZD        or sulfonylurea as monotherapy over a 3 month period or a longer        period;    -   5) statistically significant demonstration of weight loss;    -   6) no severe hypoglycemia at therapeutic dose;    -   7) no symptomatic hypoglycemia at therapeutic dose;    -   8) no fixed injection meal interval;    -   9) initiation of daily dosing requires no more than moderate        dose titration (less than or equal to 4 doses) with subsequent        daily dosing independent of blood glucose monitoring;    -   10) at least 12 months, preferably at least 18 months        refrigerated shelf-life;    -   11) room temperature in-use storage;    -   12) minimal injection site discomfort at therapeutic dose;    -   13) no injection site discomfort at therapeutic dose;    -   14) minimal nausea at therapeutic dose;    -   15) β cell preservation in animal models;    -   16) β cell preservation in humans;    -   17) injection volume between 0.1 and 0.25 mLs; and    -   18) safe for use in children.

Furthermore, the package insert may provide instructions regarding thetreatment regimen encompassed by the present invention involvingmaintaining continuous plasma levels of GLP-1 within a therapeutic rangeregardless of the patient's body weight or body mass index, sex, or age.In addition, the package insert describes how the present inventionprovides a means to maintain steady state GLP-1 levels with a protocolthat does not require the patient to self-monitor glucose levels, andthat does not need to be timed with meals thereby allowing patientconvenience while safely maintaining optimal blood glucose control.

Incidences of side effects are notably reduced due to the presentlyclaimed article of manufacture providing a chronic dosing regimen.Therefore, the preferred article of manufacture provides a packageinsert having reported incidences of nausea in less than 30% of patientswith plasma levels within the ranges described herein. More preferably,nausea and vomiting occurs in less than 20% of patients with plasmalevels within the ranges described herein. Even more preferably, lessthan 10% of patients with plasma levels within the ranges describedherein experience such side effects. Most preferably, nausea andvomiting occur in less than 5% of patients with plasma levels within theranges described herein.

Incidences of hypoglycemia due to the treatment regimen described hereinare rare. The package insert having reported incidences of hypoglycemiacharacterized by a blood glucose level less than 63 mg/dL is less than10%, preferably less than 5%, and most preferably there are no reportsof hypoglycemia.

The invention is illustrated by the following examples which are notintended to be limiting in any way.

EXAMPLE 1 Clinical Study in Type 2 Diabetics

Four groups of eight type 2 diabetic patients were treated with along-acting formulation of Val⁸-GLP-1(7-37)OH. The first three groupsreceived either 2.5 or 3.5 or 4.5 mg once a day for 6 days. The fourthgroup received 4.5 mg once per day for 21 days. On the day before thestudy, each patient received a saline injection as placebo. Bloodglucose was followed for 13 hours. All meals during the evaluation dayswere strictly standardized. Patients were outpatients except for the Day6 and Day 21 evaluations over 24 hours. Following the injection on Day1, blood samples were taken for glucose and Val⁸-GLP-1(7-37)OH plasmalevels during 4 hours. Patients were dosed each morning. On the sixthday of dosing (and also Day 21 for Group 4), samples were collected upto 26 hours post dose for the blood glucose and Val⁸-GLP-1(7-37)OHplasma level determinations. Val⁸-GLP-1(7-37)OH plasma levels arerepresented in FIGS. 1 and 3 and corresponding glucose levels arerepresented in FIGS. 2 and 4. Patients in the 21 day dosing group lostan average of 2.125 kg (standard deviation: 1.36 kg). Five subjects losta total of 3 kg, one lost 2 kg, and 2 lost no weight.

EXAMPLE 2 Determination of Val⁸-GLP-1(7-37)OH Plasma Levels

Due to the presence of endogenous concentrations of native GLP-1peptides and degradation products such as GLP-1 (9-37)OH by DPP-IV,concentrations of intact Val⁸-GLP-1(7-37)OH were measured using an ELISAassay in which full-length non-degraded Val⁸-GLP-1(7-37)OH isspecifically recognized. Immunoreactive Val⁸-GLP-1(7-37)OH is capturedfrom the plasma by an N-terminal anti-Val⁸-GLP-1(7-37)OH specificantisera immobilized onto a microtiter plate. This antisera is highlyspecific to the N-terminus of Val⁸-GLP-1(7-37)OH. Analkaline-phosphatase conjugated antibody, specific for the C-terminus ofGLP-1, is added to complete the “sandwich.” Detection is completed usingpNPP, a colormetric substrate for alkaline phosphatase. The amount ofcolor generated is directly proportional to the concentration ofimmunoreactive Val⁸-GLP-1(7-37)OH present in the sample. Quantitation ofVal⁸-GLP-1(7-37)OH in human plasma can be interpolated from a standardcurve using Val⁸-GLP-1(7-37)OH as the reference standard. Data wasanalyzed by a computer program using a weighted 4-parameter logisticalgorithm. The concentration of immunoreactive Val⁸-GLP-1(7-37)OH intest samples was determined using a standard curve.

EXAMPLE 3 In Vitro Potency Assay

HEK-293 Aurora CRE-BLAM cells expressing the human GLP-1 receptor areseeded at 20,000 to 40,000 cells/well/100 μl into a 96 well black clearbottom plate. The day after seeding, the medium is replaced with plasmafree medium. On the third day after seeding, 20 μl of plasma free mediumcontaining different concentrations of GLP-1 agonist is added to eachwell to generate a dose response curve. Generally, fourteen dilutionscontaining from 3 nanomolar to 30 nanomolar GLP-1 compound were used togenerate a dose response curve from which EC50 values could bedetermined. After 5 hours of incubation with GLP-1 compound, 20 μl ofβ-lactamase substrate (CCF2-AM—Aurora Biosciences—product code 100012)was added and incubation continued for 1 hour at which point theflourescence was determined on a cytoflour.

EXAMPLE 4 Crystallization of GLP-1(7-37)OH

GLP-1(7-37)OH was dissolved in about 0.5 mL of 0.015 N NaOH at aconcentration of about 17 mg/mL, based on the mass of the peptide. Theprotein solution was adjusted to about pH 10.5 with dilute NaOH. Thesolution was held at ambient temperature for about 1 hour.

To a 390 μL aliquot of this peptide solution was added 25 μL of a 1.0 Mglycine pH 10 solution, giving a final concentration of about 16 mg/mLof GLP-1(7-37)OH and about 60 mM glycine. The pH of the solution wasadjusted to about pH 10 with dilute HCl and/or dilute NaOH as needed.

The solution was then filtered into a glass vial through a sterile 0.22μm Millex®-GV (Millipore Corporation, Waltham, Mass., USA) 4 mm filterunit that had been pre-rinsed with 60 mM glycine buffer at pH 10.

To 300 μL of the filtered peptide solution was added 66 μL of a 50%ethanol solution in water. To this solution was added, in smallincrements, a total of 14.1 μL of a 150 mM zinc oxide pH 2.3 solution(prepared with dilute HCl), with mixing by hand performed after eachincrement was added until the solution became clear. The molar ratio ofzinc:peptide was about 1.5:1.

The final solution was adjusted to about pH 9.0 and crystallizationproceeded at ambient temperature. The crystallization solution comprisedabout 12.6 mg/mL GLP-1(7-37)OH, 47 mM glycine, 8.7% ethanol by volume,and about 1.5 moles of zinc per mole of GLP-1(7-37)OH at pH 9.0.

After 1 day at ambient temperature, thin plate crystals of GLP-1(7-37)OHwere observed under a microscope at 400× magnification.

The yield of crystallization was determined by using a spectrophotometerto compare the absorbance of an aliquot of the entire suspensionredissolved in a 10-fold dilution of 0.01N HCl, with a similarly dilutedsupernatant obtained by centrifuging the suspension for about 4 minutesat 14,000×g. For this experiment, the crystallization yield was 92%.

EXAMPLE 5 Crystallization of Val⁸-GLP-1(7-37)OH

Val⁸-GLP-1(7-37)OH was dissolved in about 0.57 mL of 0.015 N NaOH at aconcentration of about 17 mg/mL, based on the mass of the peptide. Theprotein solution was adjusted to about pH 10.5 with dilute NaOH. Thesolution was held at ambient temperature for about 1 hour.

To a 390 μL aliquot of this peptide solution was added 25 μL of a 1.0 Mglycine pH 8 solution, giving a final concentration of about 16 mg/mL ofVal⁸-GLP-1(7-37)OH and about 60 mM glycine. The pH of the solution(about pH 9.0) was adjusted to about pH 9.9 with dilute HCl and/ordilute NaOH as needed.

The solution was then filtered into a 0.5 mL Eppendorf tube through asterile 0.22 μm Millex®-GV (Millipore Corporation, Waltham, Mass., USA)4 mm filter unit.

To 300 μL of the filtered peptide solution in a clean test tube wasadded 66 μL of a 50% ethanol solution in water. To this solution wasadded, in small increments, a total of 14.1 μL of a 150 mM zinc oxide pH2.3 solution (prepared with dilute HCl), with mixing by hand performedafter each increment was added until the solution became clear. Themolar ratio of zinc:peptide was about 1.5:1.

The final solution was adjusted to about pH 8.9 and crystallizationproceeded at ambient temperature. The crystallization solution comprisedabout 12.6 mg/mL Val⁸-GLP-1(7-37)OH, 47 mM glycine, 8.7% ethanol byvolume, and about 1.5 moles of zinc per mole of Val⁸-GLP-1(7-37)OH at pH8.9.

After about three days at ambient temperature, thin plate crystals ofVal⁸-GLP-1(7-37)OH were observed under a microscope at 400×magnification.

EXAMPLE 6 Crystallization of Val⁸-GLP-1(7-36)NH₂

Val⁸-GLP-1(7-36)NH₂ was dissolved in about 0.44 mL of 0.015 N NaOH at aconcentration of about 17 mg/mL, based on the mass of the peptide. Theprotein solution was adjusted to about pH 10.5 with dilute NaOH. Thesolution was held at ambient temperature for about 1 hour.

To a 390 μL aliquot of this peptide solution was added 25 μL of a 1.0 Mglycine pH 10.2 solution, giving a final concentration of about 16 mg/mLof Val⁸-GLP-1(7-36)NH₂ and about 60 mM glycine.

The solution was then filtered into a glass vial through a sterile 0.22μm Millex®-GV (Millipore Corporation, Waltham, Mass., USA) 4 mm filterunit.

To 300 μL of the filtered peptide solution in a clean glass vial wasadded 66 μL of a 50% ethanol solution in water. To this solution wasadded, in small increments, a total of 14.1 μL of a 150 mM zinc oxide pH2.3 solution (prepared with dilute HCl), with mixing by hand performedafter each increment was added until the solution became clear. Themolar ratio of zinc:peptide was about 1.5:1.

The final solution was adjusted to about pH 9.85 and crystallizationproceeded at ambient temperature. The crystallization solution comprisedabout 12.6 mg/mL Val⁸-GLP-1(7-36)NH₂, 47 mM glycine, 8.7% ethanol byvolume, and about 1.5 moles of zinc per mole of Val⁸-GLP-1(7-36)NH₂ atpH 9.85.

After about three days at ambient temperature, microcrystals ofVal⁸-GLP-1(7-36)NH₂ were observed under a microscope at 400×magnification.

EXAMPLE 7 Crystallization of Val⁸-GLP-1(7-37)NH₂

Val⁸-GLP-1(7-37)NH₂ was dissolved in about 0.48 mL of 0.015 N NaOH at aconcentration of about 17 mg/mL, based on the mass of the peptide. Theprotein solution was adjusted to about pH 11.1 with dilute NaOH, then topH 10.36 with dilute HCl. The solution was held at ambient temperaturefor about 1 hour.

To a 390 μL aliquot of this peptide solution was added 25 μL of a 1.0 Mglycine pH 10 solution, giving a final concentration of about 16 mg/mLof Val⁸-GLP-1(7-37)NH₂ and about 60 mM glycine.

The solution was then filtered into a glass vial through a sterile 0.22μm Millex®-GV (Millipore Corporation, Waltham, Mass., USA) 4 mm filterunit.

To 300 μL of the filtered peptide solution in a clean glass vial wasadded 66 μL of a 50% ethanol solution in water. To this solution wasadded, in small increments, a total of about 7 μL of a 150 mM zinc oxidepH 2.3 solution (prepared with dilute HCl), with mixing by handperformed after each increment was added until the solution becameclear. The molar ratio of zinc:peptide was about 0.75:1.

The final solution was adjusted to about pH 9.8 and crystallizationproceeded at ambient temperature. The crystallization solution comprisedabout 12.6 mg/mL Val⁸-GLP-1(7-37)NH₂, 47 mM glycine, 8.7% ethanol byvolume, and about 0.75 moles of zinc per mole of Val⁸-GLP-1(7-37)NH₂ atpH 9.8.

After about 48 hours at ambient temperature, clusters ofVal⁸-GLP-1(7-37)NH₂ were observed under a microscope at 400×magnification.

1. A method of treating a condition selected from the group consistingof hyperglycemia and type 2 diabetes which comprises maintaining chronicsteady state plasma levels between about 60 picomoles/liter and about200 picomoles/liter of a GLP-1 analog or derivative that binds the GLP-1receptor and is in biologically active form having an in vitro potencywithin two-fold the in vitro potency of Val⁸-GLP-1(7-37)OH wherein theGLP-1 analog or derivative is administered by subcutaneous injection toa human subject no more than once or twice every 24 hours.
 2. The methodof claim 1 wherein the plasma levels are maintained between about 100picomolar and about 200 picomolar.
 3. The method of claim 2 wherein theplasma levels are maintained between about 100 picomolar and about 180picomolar.
 4. The method of claim 1 wherein the GLP-1 analog orderivative is administered not more than once every 24 hours.
 5. Themethod of claim 1 wherein the GLP-1 analog or derivative is a GLP-1analog which is administered as a crystal suspension formulation.
 6. Themethod of claim 1 wherein the GLP-1 analog or derivative is an acylatedGLP-1 derivative.
 7. The method of claim 6 wherein the acylated GLP-1derivative is a GLP-1 analog acylated at the epsilon-amino group oflysine present at position
 26. 8. The method of claim 7 wherein theacylated GLP-1 derivative isArg³⁴Lys²⁶-(N-ε-(γ-Glu(N-α-hexadecanoyl)))-GLP-1(7-37).